#Clinical_case 29

An 8-year old girl has been brought to the hospital with a complaint of generalized skin manifestations. The young girl was taken to a local clinic on an outpatient basis about 10 days ago following a sore throat and fever.
The physician diagnosed her with a cold and started Amoxicillin for her. 3 days after start taking amoxicillin, she developed skin rashes that started on the head and face that spread to the chest and abdomen after a few hours that was accompanied by lip swelling and dyspnea. Following a quick visit to a hospital, hydrocortisone and clindamycin was prescribed for her.
During hospitalization, swelling of the lips and dyspnea improved, but skin rashes spread to the back and buttocks.

📌 Physical examinations:

Neck 👉 Small 1*1cm lymph node on the lateral side of the neck

Pharynx 👉 Erythema and brief hypertrophy of the tonsils without exudate

Skin 👉
Palpable purpura, generalized on the skin that faded with pressure but doesnt disappeared completely.

(See the pictures below)

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1⃣ Differential diagnosis?

2⃣ Required laboratory tests?

3⃣ Management?

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📌 Thoracentesis
📌 Pleural tapping

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📌 Asthma treatment

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✅ Management of GI Bleeding


📌 Check ABC
📌 Cardiac monitoring and P.O
📌 Oxygen supplement therapy
📌 Lab tests
📌 Serial ECG
📌 IV fluid therapy
📌 Monitoring Hgb level
📌 NGtube placement
📌 Blood transfusion
📌 Proton pump inhibitors
📌 Prokinetics
📌 Octreotide
📌 Band ligation
📌 Antibiotic
📌 Surgical consultation



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#Clinical_case_answer 29

1⃣ Differential diagnosis:

1) Drug eruption
2) Infectious mononucleosis
3) Serum sickness
4) Scarlet fever
5) SJS
6) Kawasaki disease
7) Angioedema
8) Vasculitis
9) Exanthematous pustulosis
10) DRESS syndrome

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2⃣ Required lab tests:

📌 CBC diff
📌 ESR, CRP
📌 Liver function tests
📌 Peripheral blood smear
📌 PCR-covid19
📌 Heterophile Ab
📌 Throat smear

🔔 Discussion:

Clinical manifestations such as palpable purpura, angioedema, lymphadenopathy and generalized skin rashes are suggesting drug sensitivity reaction. For definite diagnosis, we need to follow patients symptoms and its progrssion, while we take a look on lab results. Complete blood cell count with differential (looking for eosinophilia, which supports the diagnosis and also occurs in patients with drug rash with eosinophilia and systemic symptoms [DRESS]), neutrophilia, as in acute generalized exanthematous pustulosis (AGEP), or to identify cytopenias.Liver and kidney function tests (looking for systemic involvement which may occur in patients with DRESS or Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN).

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3⃣ Management:

1) Drug withdrawal
2) Symptomatic treatment e.g,

📌 Oral diphenhydramine 25-50mg q4-6h

📌 Oral hydrocortisone 25mg q8h

📌 Oral citerizine 10mg daily

⚠️ We suggest not routinely using systemic corticosteroids for the treatment of uncomplicated exanthematous drug eruptions. However, in patients with drug-induced rash and systemic or cutaneous symptoms suggesting a severe cutaneous reaction, a short course of moderate/high-dose systemic corticosteroids (eg, prednisone 1 to 2 mg/kg per day for five to seven days) may be beneficial.

4) Patient education:

During the acute phase of the drug reaction, patients should be educated about warning signs of more severe hypersensitivity reactions. These include:

📌 high fever
📌 facial edema
📌 mucosal symptoms
📌 skin tenderness
📌 blistering.

This patient got better gradually just with prescription of oral diphenhydramine without any corticosteroid.

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✅ Final diagnosis:

#Drug_eruption

#Clinical_case_31

A 51-year old woman was struck by an motorcycle in the street. She sustained bi-frontal cerebral contusion, a right tibial plateau fracture and abdominal trauma. At the 4th day of hospitalization, she develops respiratory distress and transferred to the ICU.

📌 Physical examination:

BP = 130/75mmHg
PR = 104 bpm
RR = 33 breaths/min
T = 37.1°c
GCS = 15

Chest X-Ray 👉 Normal

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1⃣ What is the risk factors for her respiratory condition?

2⃣ Differential diagnosis?

3⃣ Most likely diagnosis?

4⃣ Priorities in the management?

#Clinical_case_answer_31

1⃣ Risk factors:

1) Stasis (bed rest, immobilization)
2) Hypercoagulopathy (Trauma, estrogen)
3) Endothelial injury (trauma)
4) Age > 40
5) Lower extremities fracture
6) Brain injury

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2⃣ Differential diagnosis:

1) Pulmonary embolism
2) Pneumothorax
3) Mucus plugging
4) Cardiac ischemia
5) Fluid overload

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3⃣ Most likely diagnosis:

💠 Pulmonary embolism

🔷 Discussion:

Most PEs occur when a thrombus breaks free from the endothelial wall, traveling through the right heart, and lodging in the pulmonary artery. PE causes ventilation/perfusion mismatching, increased pulmonary vascular resistance, and cytokine mediated pulmonary vasoconstriction. Symptoms depend on the degree of pulmonary arterial obstruction, severity of the inflammatory response, and the patient's physiological reserve. Most patients have dyspnea, while some patients have hypoxemia. At times, extravasation of blood into the alveoli can produce pleuritic chest pain, cough, or hemoptysis.

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4⃣ Priorities in management:

📌 Determine adequecy of oxygen and ventilation
📌 Airway protection
📌 High-flow oxygen
📌 ECG

⚠️ T-wave inversions in lead V1 and V2 may be present on EKG and are 99% specific for PE.

📌 Contrast-enhanced Abdominal and pelvic CTscan
📌 Anticoagulant therapy

⚠️ Empiric anticoagulation should be considered in high-risk patients without significant bleeding risks. Treatment with either unfractionated heparin or LMWH is acceptable. Hemodynamically unstable patients with large central PEs can be considered for catheter-directed therapy such as catheter-directed thrombolytic therapy or catheter-directed mechanical clot disruption therapy.

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✅ Final diagnosis:

#Pulmonary_embolism